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HEART FAILUREAYSAR RIYADH AYSAR RIYADH
13301701330170
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GENERAL SIGNS AND SYMPTOMS
March 2013ghennersdorf DGK ESC SES2
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DEFINITION OF HEART FAILURE CHF
New York Heart Association (NYHA) I no visible signs and symptoms II signs and symptoms at high level exercise III signs and symptoms at low level exercise IV no physical exercise possible, bed rest
necessary
March 2013ghennersdorf DGK ESC SES3
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TREATMENT GOALS
March 2013ghennersdorf DGK ESC SES4
IV
III
II
I
??
??
??
HTX option
Main treatment goalfor chronic disease
Main treatment goalfor acute disease
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THERAPEUTIC OBJECTIVES
Acute CHF Treatment of life threat Improvement of life quality
Chronic CHF Improvement of life quality Reduction of Disability Increase of longevity
March 2013ghennersdorf DGK ESC SES5
Adding life to years rather than years to life
Main approachVasodilation
Organ protectionVolume control
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THERAPEUTIC OPTIONS
March 2013ghennersdorf DGK ESC SES6
Acute Heart Failure
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THERAPEUTIC OPTIONS (ER, ICU)
Physical approach in cardiogenic pulmonary edema Oxygen delivery Bed rest / upright position Secure (central) venous line Urinary catheter Blood letting
Drugs (iv administration) Diuretics (short term, furosemide) Digitalis (?; fast AF ?) Thrombembolic prophylaxis (heparin; PTT necessary)
Drugs orally (cave hypotension) Nitroglycerine sublingually Consider ACEI sublingually
March 2013ghennersdorf DGK ESC SES7
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THERAPEUTIC OPTIONS (CARDIOGENIC SHOCK)• Volume expansion under hemodynamic control
– Pulmonary artery cath– Arterial pressure line
• Mechanical assistance: IABP• Cathlab: PCI• Surgery: revascularization• Drugs
– Catecholamines: Dopamin, Dobutamin– Phosphodiesterase (PDE)-Inhibitors: Amrinone, Milrinone (not evidence based)– Thrombembolic prophylaxis: heparine (PTT)– Fast acting diuretics
• Acid base control• Electrolyte contol (potassium)
March 2013ghennersdorf DGK ESC SES8
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THERAPEUTIC OPTIONS
March 2013ghennersdorf DGK ESC SES9
Chronic Heart Failure
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EVIDENCE
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THERAPEUTIC CHALLENGE
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Systolic heart failure: mostly common in CHD and RHDDrugs and recommendations according to guidelines
Diastolic heart failure: mostly common in hypertensionLong term follow up dependent on treatment of underlying diseaseDrugs recommendations not yet established
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THERAPEUTIC OPTIONS
First line recommendation: Prevention Prevention of CHD, Hypertension, valvular disease, infections Information, home care, transmission of simple behavior rules:
Hygiene and clean water supply Motion: physical activity, limited sport action Nutrition: salt restriction Refrain smoking
March 2013ghennersdorf DGK ESC SES12
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THERAPEUTIC OPTIONS Conservative
RAS modification ACE-I AT1-receptor antagonists Aldosterone antagonists (Eplerenone ®)
beta-AR competition Betablockers
classical 3D options Diuretics (fast acting, medium acting; cave potassium) Diet Digitalis (?) not first choice!
Others: (Pulmonary artery Hypertension) Bosentan Sildenafil
ghennersdorf DGK ESC SES
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ß-BLOCKADE IN CHF
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ß-BLOCKADE IN CHF
March 2013ghennersdorf DGK ESC SES15
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ß-BLOCKADE IN CHF
March 2013ghennersdorf DGK ESC SES16
Muscle cell; contractilityNENEE
Muscle cell; contractility
NENENENEEEE
Muscle cell; contractility
NENENENEEEE
Betablockade: receptor recovery,function improves
AR Reduction
AR Recovery
Reduction of adrenergic receptors AR
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ß-BLOCKADE IN CHF
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THERAPEUTIC OPTIONS. ACE-I
Trials CONSENSUS 1987 Captopril SOLVD 1999 Enalapril SAVE 1992 Captopril VHEFT 1991 Enalapril/Hydralazin CIBIS III 2005 Enalapril/Bisoprolol
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Demonstrate highly significant improvement of survival in different stages of heart failure (II –IV): Evidence Class A - IA
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DOSAGE RECOMMENDATIONS
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DOSAGE RECOMMENDATIONS
March 2013ghennersdorf DGK ESC SES20
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IMPROVEMENT OF HF IN CARDIAC CXR
March 2013ghennersdorf DGK ESC SES21
before treatment after treatment
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THERAPEUTIC OPTIONS
Surgical Heart transplantation, bridging Cardiomyoplasty
Resynchronizing pacemaker therapy (CRT) Stem cell replacement
March 201322
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THERAPEUTIC OPTIONS
HTX Surgically solved Concomitant therapy problems (rejection) solved Donor problems unsolved and will persist
March 2013ghennersdorf DGK ESC SES23
But: therapeutic choice for subsets of younger patients with severe symptoms mostly on
iv therapy and/or ICU care without chance to recover appropriately.
Bridging procedure desirable
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HEART TRANSPLANTATION HTX
March 2013ghennersdorf DGK ESC SES24
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HEART TRANSPLANTATION
March 2013ghennersdorf DGK ESC SES25
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HEART TRANSPLANTATION
March 2013ghennersdorf DGK ESC SES26
3rd september 1967original OR theatreGroote Schuur HospitalCape Town SAR
Christian Neethling Barnard
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ARTIFICIAL HEART
March 2013ghennersdorf DGK ESC SES27
Heartmate® for bridging procedures
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SURVIVAL AFTER HTX
March 2013ghennersdorf DGK ESC SES28
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THERAPEUTIC OPTIONS: CARDIAC RESYNCHRONIZATION THERAPY CRT
March 2013ghennersdorf DGK ESC SES29
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THERAPEUTIC OPTIONS
March 2013ghennersdorf DGK ESC SES30
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THERAPEUTIC OPTIONS: RESYNCHRONIZATION THERAPY
March 2013ghennersdorf DGK ESC SES31
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THERAPEUTIC OPTIONS: STEM CELLS
March 2013ghennersdorf DGK ESC SES32
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THERAPEUTIC CHALLENGE: HOME CARE
Medication starts in the hospital Medication continues in household enviroment, rural areas Doctor‘s contacts rare Patient‘s survey difficult. Therefore: narrow control schedules concerning
Nurse directed home care Continuous medical education of both patient and personal (nurses/doctors) Outpatient visits Establishing telemedical processes
March 2013ghennersdorf DGK ESC SES33
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THERAPEUTIC HOME CARE OPTIONS
Home care (nurse driven) Scheduled visits on regular basis (nurse, AMO) Visits following questionnaire Data acquisition and transmission
(telemedicine?) Severity of symptoms Daily activities ability Controls
Medication Weight (listing by patient) Blood pressure other
March 2013ghennersdorf DGK ESC SES34
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CHF QUESTIONNAIRE; EXAMPLE
March 2013ghennersdorf DGK ESC SES35
How do you feel since last visit? Scale of 10 ptsIn your opinion, are there main changes:
breathingweight gainUrinary outputpalpitation?
How do you think developed your personal daily activities (DAs)?
worsesamebetter
which kind of DAs is mostly impaired?homeleisureemployment
What about your medication:intake OK?complaints?self made changes?incompatibilty?wishes?
Suggestions?
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HEART NETWORK
March 2013ghennersdorf DGK ESC SES36
Patient
Hospital
Home Care
OPD
District Hospital
Dispensary
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HEART NETWORK: NURSE
March 2013ghennersdorf DGK ESC SES37
+
Hospital
Nurse
home care
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HEART NETWORK: INTERNET
March 2013ghennersdorf DGK ESC SES38
Patient data file, database: EPF*Access by authorized personal throughout the country
*electronic patient file
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HEART NETWORK
Telecardiology (telemedicine) Electronic provision of data transmission Generation of medical data in remote areas (rural) Overcoming of doctors shortages Secure transmission line Targets:
Hospital Centers Home care physician Home care nurse Specialized medical call centers
March 2013ghennersdorf DGK ESC SES39
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HEART NETWORK
Telemedical patient kit Smartphone with Apps (Skype) Balance ECG device Blood pressure device Glukose test kit Finger tip pulse oxymeter Questionnaire
March 2013ghennersdorf DGK ESC SES40
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THE END
March 2013ghennersdorf DGK ESC SES41